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General NPI Number Information
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NPI Number | 1588613384
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Entity Type | Organization
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Legal Business Name | LAKE OF DECATUR INC
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Dates
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Enumeration Date | 05/09/2006
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Last Update Date | 10/21/2021
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Provider Practice Location Address
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Address Line | 245 W 1ST DR STE B
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City | DECATUR
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State | IL
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Zip | 62521-5381
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Country | US
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Telephone | 217-429-5165
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Fax | 217-429-5172
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Provider Business Mailing Address
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Address Line | 245 W 1ST DR STE B
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City | DECATUR
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State | IL
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Zip | 62521-5381
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Country | US
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Telephone | 217-429-5165
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Fax | 217-429-5172
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Authorized Official
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Title or Position | PRESIDENT
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Name | DALE COLEE
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Credential |
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Telephone | 217-429-5165
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336L0003X
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Taxonomy Name | Long Term Care Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 3336M0003X
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Taxonomy Name | Managed Care Organization Pharmacy
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 54.015385
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License Number State | IL
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